Provider Demographics
NPI:1598100117
Name:DETOY, KELLY ELYSE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELYSE
Last Name:DETOY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NICOLLS ROAD
Mailing Address - Street 2:STONY BROOK UNIVERSITY HOSPITAL
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794
Mailing Address - Country:US
Mailing Address - Phone:631-444-4000
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK UNIVERSITY HOSPITAL
Practice Address - Street 2:101 NICOLLS ROAD
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD466262208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program